BP-83717RESIDENTIAL 11 Phased Approval (R 106.3.3)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON -TRANSFERABLE
S C-T16K 1 15� -.E E, �ORMik=
1.1 Property Address:
Contact Person: : "t, N-.— ar-,-
Phone Number: 5-09— qgf-31y,(,
1.4 Water Supply (MGL c40 s54): Sewage Disposal System:
0 Municipal 11.5
0 Municipal
[I Private Well
0 On Site Disposal System
1.2 Assessors Map & Lot Number:
Map 33 Lot
1.3 Historical District 0 Yes 11 No
Year Built
0 Altering more than 25% per side of buildiing
Has application been submitted to the Historic Commission?
r-1 Yes 0 No Date: I
El CONSTRUCTION PLANS ❑SITE PLAN
Revised b / 16
1:1 ENERGY RF)ORT
2.2 Au�horizedAgont
Name (print)
Uontact Address Phone Number
Contact Address Phone Number
3.1 Licensed Construction Supervisor/Specialty License- icens
company Name/Contractor Name: Number: 0 S -Zo.5-037`1
Ad
3.2 Homeowner Exemption - One & Two Family Only Section I I O.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exception: Any Homeowner Performing work for which aBuilding Permit mrequired shall unexempt from the provisions mthis section;pm,mo m�noon nnounn'aPem»n(o)m'»m'�uvsu'mwom.mntsuo»xomemvne,nnui|amanuvpewuo� °" Homeowner
r»'m*nu�v�m�m/s'ommnnn�u`xomemwnv�ummneuaom//oxm: Pamnn(4who �parcel of
mxapo|onoonwm/cnxe�hpmom/onn,.mnuommomo onwm/m th
em�nm,uwbe, oone o,�mmmoy�mmoo.aua�euoroe�vxuo�mmumnnmm,00�msuch use o^mfa
rm usAperson who cvoouo'—nmmo� man one»^mema�n�»o'nenouohoxnmuem,nsiuem«a*omomme,.
If you are applying under this section sign below:
^
Worker's Compensation Insurance Affidavit must be completed and submitted with this application��m�����
affidnv�w��suk��odonkdof�ekmuonceof�ebuUd�gpnrm� Signed AfOdavbAttached: OYea ONo
[]Deck []Pool []Repairs []Alteration []Chimney/Fireplace []VVoodstove/PeUetStove
[] New Construction* [] Accessory Bldg. []Addition ~�~�'n Rop/ooamantwindo
(E»*rDYe*P»drequired) (Shed/Garage) (Energy mpo�nequimd) ^~'`"o�[]window/door No. o[w�dowm_g� Doors
ODEMOLITION :
Location of debris removal (per MGL C.40 Sec 54):
Facility Name:
*If new oonst.rUcbonplease complete the following:
Single Family: No. of Bedrooms
UDumpsteronsite ODumpsterOnStreet
No. of Baths
Two Family: NoofBedrooms Unit 1 No. ofBaths Unit 1
NoofBedrooms Unit 2 No. ofBaths Unit 2
0 Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
OBoiler (heaUmg)-fuel gas (natural nrpmpune), fuel oil, electricity, other (spnody': --
OHVAC(combined unit) 'phmory�e!.n�uno|gas, pmpano.e|n�ho8y.n�or(op--'
OAjrcnndiUon/ng'(oepa��uniV ''
ElNone o[the above mbeprovided
OHot Water: GuoBectncFuel Oil
Item Estimated Cost ($) to be completed by permit applicant
1 Building
2. Electrical
3. Plumbing
NER-
TAI
cb
(Please Print)
1, as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work ed by thi uilding permit application.
:T,01�lz
Signature of Owner Date
1, as Owner/Authorized Agent hereby declare that the statements and informattion
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
SignatG-re of Owner/Authorized Agent Date
POOP" TO
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
Gross Area - New Construction total sa. ft.